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New York Claims Information

Below are many of the common claim forms you will need when filing a claim in New York State. A complete list of all common New York State Workers’ Compensation Board forms may be found on the Workers’ Compensation Board’s web site:

http://www.wcb.ny.gov/content/main/Forms.jsp

Employer Claim Information and Forms

Document What It Is When To Use/File
Welcome kit Welcome letter for employers entering the Oryx Insurance construction program. Kit includes welcome letter, contact listing and information on our loss control services. Whenever an injury occurs.
Contact Listing State specific claim contacts Use as directed
C-2F Employer’s first report of injury.
(This PDF form may only be browser viewable in Internet Explorer browsers, please download the PDF to your computer and open it locally using Acrobat Reader if you have problems viewing this PDF file in a browser)
As soon as possible after accident, or injury occurs.
C-3 Employee’s application for workers’ compensation benefits because of a work injury or work-related illness. As soon as possible after accident, or injury occurs.
C-11 (8/09) Paper Version Employer’s Report of Injured Employee’s Change in Status or Return to Work As soon as employment status of injured employee changes.
C-240 (8/09) Paper Version Employer’s Statement of Wage Earnings Preceding Date of Accident Within 10 days of request by the Board.
Claimant Information Packet When an employee is injured due to a work-related accident or becomes ill due to exposure, the employer or its designee must provide the injured worker with the Claimant Information Packet as soon as possible. The employer or its designee must note on the C-2F form  that the packet was given to the injured worker. (NOTE: THE C-2F FORM IS NOT INCLUDED IN THIS PACKET, PLEASE DOWNLOAD FROM THE LINK ABOVE) Whenever an injury occurs.
Pharmacy Benefits Information on the injured employee’s pharmacy benefits for all medications associated with his/her work-related injury. Injured employee must present the form to the participating pharmacy to receive authorized medication at no out-of-pocket expense.

If you have a question related to a claim, please call 315-410-0210

Employer’s Responsibility for Filing a Claim

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